Growth and Nutrition
Weight and body composition offer information about an individual’s health status and may provide a clue to the presence of disease when they are out of balance. Nutrition is considered…
Mental Status
The mental status portion of the neurologic examination is a complex process. Mental status is the total expression of a person’s emotional responses, mood, cognitive functioning (ability to think, reason,…
Vital Signs and Pain Assessment
The vital signs include assessment of temperature, pulse, respiration, and blood pressure. They are considered the baseline indicators of a patient’s health status. Pain assessment is considered the fifth vital…
Recording Information
After performing the history and physical examination, the healthcare provider must organize, synthesize, and record the data along with the problems identified, diagnostic evaluation, and plan of care. The information…
Examination Techniques and Equipment
This chapter provides an overview of the techniques of inspection, palpation, percussion, and auscultation that are used throughout the physical examination. In addition, general use of the equipment for performing…
Taking the Next Steps: Clinical Reasoning
Clinical reasoning is the process by which the information gathered from the history and physical examination is merged with clinical knowledge, experience, and the current best evidence to formulate the…
Cultural Competency
Achieving cultural competence is a learning process that requires self-awareness, reflective practice, and knowledge of core cultural issues. It involves recognizing one’s own culture, values, and biases and using effective…
The History and Interviewing Process
This chapter discusses the development of relationships with patients and the building of the histories or healthcare narratives. We write of it as “building” a history rather than “taking” one…
